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Evaluating Candidates for Bariatric Surgery: Why Accurate Testing Matters

Determining eligibility for bariatric surgery is a complex and detailed process involving a multidisciplinary team that combs through a potential candidate’s medical history, mental health evaluations, lifestyle habits, and psychological preparedness before making a crucial and potentially life-changing decision. Mental health professionals are essential to helping candidates achieve successful surgical outcomes. But to accurately assess a candidate’s potential for success, they must utilize precise and suitable assessments that include specific data for individuals undergoing bariatric surgery. Yet not all tests yield the same information. 

This article delves into the common issues psychologists face when conducting presurgical assessments and how they can navigate these challenges to ensure optimal patient outcomes. We shed light on the importance of employing appropriate evaluation methods based on presurgical bariatric surgery candidate norms and focus on why simply relying on comparison group profiles falls short of providing accurate insights.  

Behind the bariatric psych evaluation  

Presurgical psychological assessments began in the 1980s when researchers started consider psychosocial factors that were influencing the success of bariatric surgery patients. Why were some individuals successful postsurgery and others were not? Today, psychological testing is often required as part of a routine examination for bariatric surgery candidates. Many multidisciplinary teams use psychological testing to screen for factors that, if left unattended, may negatively impact surgical results. Patients are assessed concerning symptoms of mental health disorders such as depression, anxiety, psychosis, suicidal ideation, substance abuse, family history of mental health issues, and any treatment experiences. 

A psychological evaluation can help identify candidates' strengths, such as if they are motivated to exercise, if they completely understand the effects of surgery, or if they will be able to take on the unique care needs of the procedure during both the postoperative period and in the long term. These assessments also uncover areas where patients might need aid after surgery, pointing out things such as a lack of family support, the understanding of continuity of care, triggers for past emotional eating, or mental health challenges such as depression. Studies suggest that patients with specific psychosocial stressors may pose a higher risk for postoperative complications:  

  • Research indicates that 10–25% of patients tend to have weight regain. 
  • Postoperative complications due to poor compliance with treatment recommendations impact 5–25% of patients. 

Furthermore, a small minority of patients may experience severe psychological complications, including depression, suicidality, and alcohol abuse—particularly after the "honeymoon period" (1 to 2 years postsurgery) has passed. Studies suggest that worsening mental health postsurgery might be due to a higher level of psychiatric complexity at baseline. Other research indicates that some patients go into surgery with unrealistic expectations about weight loss and its impact on their lives, or face issues with malabsorption of psychiatric medication after surgery.  

Mitigating psychological difficulties involves support from the bariatric team before and after surgery. Psychologists play an integral role within the team to aid with the assessment and treatment of these patients with the goal of successful surgical outcomes. One thing is clear: the need for valid testing. Psychologists need an appropriate and accurate assessment with specific normative data for bariatric surgery patients.  

Why accurate testing and specific normative data matters 

Psychologists are looking to make presurgical psychological evaluations more accurate and less taxing, according to the American Psychological Association. With this in mind, the Bariatric Times suggests that psychologists should ensure the instruments being used are appropriate for the population when selecting psychological measures for standard presurgical evaluation. The assessment should have a medical standardization sample rather than only psychiatric norms or norms representing the general population.  

Measures with bariatric norms are ideal because strengths or weaknesses can be seen in a proper comparison group. For example, knowing that a patient's depression is more than a standard deviation greater than other bariatric patients can put the need for treatment into a more accurate context. However, not all tests yield the same benefit. When selecting an assessment, the more detailed the data is, the better the outcomes.  

With this understanding, psychologists need an appropriate evaluation with specific normative data for bariatric surgery patients. More precisely, they should have results based on presurgical bariatric surgery candidate norms and not just comparison group profiles.  

For example, one assessment, the PAI Bariatric Score Report, includes normative scores from a sample of successful bariatric surgery candidates derived from archival data collected during psych evaluations at an outpatient health psychology clinic. A candidate was considered successful if they received follow-up care for a least 1 year postsurgery and achieved 50% of or more loss of excess body weight at their last follow-up appointment. This accurate information helps providers: 

  • Identify and treat preexisting psychopathology before surgery. 
  • Determine which patients may need additional postoperative care.  
  • Supply alternative treatment strategies if the patient is not deemed a candidate for the procedure they are seeking. 
  • The need for a standard, holistic preoperative assessment tool 

Another concern when it comes to presurgical assessments is that providers are using different assessments. Because psychological factors impact postsurgical weight regain, preoperative evaluations are essential in determining which bariatric candidates will achieve a healthy weight and maintain weight loss over time. As there is no gold-standard instrument to evaluate the psychological well-being of bariatric patients, providers utilize various assessments. The result? Different tests and measures can result in different interpretations. This can yield inconsistent results and poor surgical outcomes.  

Providers that use a comprehensive psychological measuring tool, especially one with specific normative data for bariatric surgery patients, can accurately streamline the decision-making process when determining surgical candidacy. Standardized instruments with norms and clinical cut-offs can also help refine diagnoses, leading to more effective treatment. 

Final thoughts 

Psychologists rely on accurate pre-operative testing to ensure adequate selection and postsurgical support for eligible candidates. Adopting appropriate assessment methods based on presurgical bariatric surgery candidate norms can make all the difference in patient outcomes and overall health. 

Learn more about the PAI Bariatric